Acute appendicitis in children: is preoperative hyponatremia a predictive factor of perforation/gangrene? A prospective study.

PURPOSE: Distinguishing between perforated/gangrenous from uncomplicated appendicitis in children helps management. We evaluated hyponatremia as a new diagnostic marker for perforated/gangrenous appendicitis in children. METHODS: A prospective study including all children with acute appendicitis who underwent appendectomy at our institution from May 2021 to May 2023. Medical history and clinical criteria were analyzed. All blood samples were taken upon admission including serum inflammatory markers and electrolytes. Patients were divided into two groups (Group I: uncomplicated and Group II: perforated/gangrenous), and data between both groups were compared. RESULTS: The study included 153 patients [Group I: 111 (73%), Group II: 42 (27%)]. Mean serum sodium concentration in children with perforated/gangrenous appendicitis was significantly lower compared to children with uncomplicated appendicitis (131.8 mmol/L vs. 138.7 mmol/L; p < 0.001). The ROC curve of preoperative sodium level to differentiate between perforated/gangrenous and uncomplicated appendicitis revealed an AUC of 0.981. The cut-off-value of sodium level < 135 mmol/L identified perforated/gangrenous appendicitis with a sensitivity of 94% and a specificity of 91% (p < 0.001). Predictive factors of perforated/gangrenous appendicitis were: age less than 5 years (12% vs. 3%; p = 0.02), experiencing symptoms for more than 24 h (100% vs. 58%; p < 0.001), body temperature more than 38.5 °C (52% vs. 13%; p < 0.001), a serum sodium level less than 135 mmol/L (90% vs. 6%; p < 0.001), and a CRP serum level more than 50 mg/L (71% vs. 17%; p < 0.001). CONCLUSIONS: Hyponatremia, upon admission, is a novel, objective biochemical marker that can identify perforated/gangrenous appendicitis in children. We advocate that the assessment of serum sodium level should be added to the diagnostic algorithm in children with suspected acute appendicitis. Surgical intervention in patients with hyponatremia should not be delayed, and non-operative management should be avoided.

Peri-Kasai portoenterostomy sutures anchoring the jejunal loop to Glisson capsule: A novel modification to reduce the incidence of cholangitis.

BACKGROUND: Kasai portoenterostomy (KPE) is the standard surgical management for biliary atresia (BA). To improve the outcome these infants were operated on within the first two months of life. The success of the procedure is reflected by clearance of jaundice and either absence or occurrence of fewer attacks of cholangitis. The failure of the procedure indicates liver transplantation (LT). OBJECTIVE: to reduce the incidence of the recurrent attacks of cholangitis by peri-KPE sutures anchoring the jejunal loop to the Glisson capsule. METHODS: It is a retrospective study that included 45 infants diagnosed with BA and who were operated on at an age younger than 60 days. They were categorized into two groups, Group A (n = 23) included infants treated with the classic KPE, and Group B (n = 22) included infants treated in the same way plus peri KPE sutures anchoring the jejunal loop to the Glisson capsule. RESULTS: The mean operative time in Group A was 149.3 min versus 164.8 min in Group B (p-value 0.039). The mean level of bilirubin was 2.2 versus 2.1 in Group A and Group B respectively at two years follow up. The total attacks of cholangitis per patient were significantly lower in Group B than in Group A (cutoff value = 3), which was reflected by the significant reduction of the incidence of LT in Group B. CONCLUSION: peri KPE sutures anchoring the jejunal loop to the Glisson capsule significantly reduced the incidence of recurrent attacks of cholangitis and subsequently decreased the requirement of LT on the short-term follow-up.

Hybrid Mathieu Urethroplasty vs. Tubularized Incised Plate Urethroplasty for the Management of Distal Penile Hypospadias With a Small Glans.

Introduction: Distal hypospadias is a common anomaly. Different surgical techniques have evolved through the years to manage this anomaly. Several factors may affect the prognosis. One of them is glans size. We compared the hybrid Mathieu urethroplasty (HMU) and the tubularized incised plate urethroplasty (TIPU) for the management of distal hypospadias with a small glans. Methods: Sixty-eight patients with distal hypospadias were included and categorized into two groups. Group A (n = 33) and group B (n = 35) patients were treated by HMU and TIPU, respectively. All patients had a small glans. In group A, the patients underwent Mathieu urethroplasty plus a deep incision of the urethral plate. In group B, the patients underwent TIPU. Urethral stents were used in all cases. Hypospadias objective score evaluation (HOSE) was used to assess the results. Results: Urethrocutaneous fistulae developed in two cases in group A and six cases in group B. Meatal stenosis was significantly lower (one case in group A vs. eight cases in group B). Glanular dehiscence occurred in two cases in group A and five cases in group B. The small glans strongly correlated with the development of both urethrocutaneous fistulae and meatal stenosis where the odd ratios were 3.500 (1.383-7.879) and 9.481 (1.114-12.669), respectively. Conclusion: Both techniques showed efficacy during management of patients with a small glans. HMU had better outcomes, shorter duration of stent and lesser incidence of complications than TIPU. Small glans was significantly related to urethrocutaneous fistulae and meatal stenosis in group B.

Delayed vs. early enteral feeding after repair of congenital recto-vestibular fistula: The effect on perineal wound healing.

Introduction: congenital Recto vestibular fistula represents the commonest type of anorectal malformation in females. The treatment of this anomaly is mainly approached either through anterior or posterior sagittal ano-rectoplasty approach. Several perioperative factors may affect the outcome. One of major postoperative complications is the occurrence of wound infection. We aimed to study the effect of delayed vs. early enteral feeding on the occurrence of perineal wound infection (PWI) after repair of congenital recto vestibular fistula. Patients and methods: Fifty-five infants with recto-vestibular fistula were included. They were managed by single stage anterior sagittal anorectoplasty (ASARP) at an age ≥3 months. Groups A and B included infants who started oral intake on the 6th and 2nd postoperative days respectively. Group A infants were kept on peripheral parenteral nutrition (PPN) during the fasting period. Results: Superficial wound infection occurred in three cases in group A while it developed in seven cases in group B. Deep perineal infection occurred in two and five cases in group A and group B respectively. The mean hospital stay was 8 days in group A vs. 13 days in group B when PWI developed. Conclusion: Delayed enteral feeding with PPN keeps the perineal wound less contaminated with stool. This promoted proper and fast healing with lower incidence of PWI. Also, PPN compensates the catabolic effects of both surgical trauma and fasting during the postoperative period and ensures maintenance of normal levels of essential nutrients that allow for proper healing.

Predictive factors of post-laparoscopic appendectomy peritoneal collection in children and adolescents with complicated appendicitis.

INTRODUCTION: Intra-peritoneal collection (IPC) following laparoscopic appendectomy (LA) of complicated appendicitis in children is a serious complication. This is associated with a longer duration of hospital stay, more costs, and psychological upsets of both children and their parents. The aim of this study is to evaluate different factors that may affect the development of IPC following LA of complicated appendicitis. PATIENTS AND METHODS: Seventy-five children were admitted with acute complicated appendicitis. All of them had LA between January 2016 and October 2020. The following variables were studied: patients' demographics, clinical findings, laboratory and imaging studies and operative parameters. Patients were divided according to their post-operative course into two groups; Group (A): patients with IPC (n = 19), Group (B): patients without IPC (n = 56). Potential risk factors for the development of post-operative IPC were identified by univariate and multivariate logistic regression analysis. RESULTS: Nineteen cases (25.3%), out of 75 patients, presented with post-operative collection. Forty-seven (62.7%) patients were males, the overall median age was 11 (inter-quartile range [IQR] 10-13). The most significant operative variable was the operative time, which was significantly longer in Group A, 78 min (IQR 75-88) versus 56 (50-66), P = 0.001. The following variables were associated with an elevated incidence of post-operative IPC; age, body mass index, total leucocytic count (TLC), duration of symptoms, pediatric appendicitis score, pre-operative morbidity, being on medications, operative time, suction and irrigation or suction only and drain duration. In the multivariate model, TLC (odds ratios [OR]: 1.358, P 0.006), symptoms duration (OR: 2.051, P 0.012), morbidity (OR: 2.064, P 0.041) and operative time (OR: 2.631, P 0.039) were statistically significant and confirmed as being predictors of IPC post-LA in complicated appendicitis. CONCLUSION: Post-operative IPC is quite common after LA for complicated appendicitis. Increased TLC, prolonged symptoms duration, associated co-morbidity and operative time could be predictors of its occurrence. Improving general condition, surgical technique and reducing operative time help to reduce its incidence.

Prognostic scoring system of laparoscopic splenectomy in children with benign hematological diseases, a retrospective cohort study.

PURPOSE: laparoscopic splenectomy (LS) gained popularity during the last years among pediatric surgeons. Benign hematological diseases represent the main indications of that procedure. There are some score systems of difficulty of the technique. Most of them are for adult patients. The aim is to develop a prognostic score system of LS in children with benign hematological diseases. METHODS: LS was performed in all children with benign hematological diseases. The children were operated in lateral decubitus position. The control of pedicle was achieved using bipolar sealing devices, polymer clips or endoscopic linear stablers. Preoperative, operative, and postoperative data were recorded and analyzed. Children were divided into two groups A and B according to the onset of complications. RESULTS: 137 successive children were operated. The mean age of patients was 8.7 (4-15) years. The main indications of LS were thalassemia, spherocytosis, idiopathic thrombocytopenic purpura (ITP), and sickle cell anemia (SCA). The mean length of splenic axis in thalassemia and spherocytosis cases was15.6 ± 2.3 cm. The mean amount of estimated blood loss (EABL) was 149 ± 43.2 ml in group A while it was 185 ± 44.4 ml in group B. The mean operative time in group A was 75.5 ± 22.5 min while it was 89.2 ± 20.6 min in group B. CONCLUSION: the development of prognostic score of LS in children with benign hematological diseases can predict children who are more susceptible for complications. It helps to minimize these complications and improve the outcome of LS.

Diagnosis of acute appendicitis in children using urinary 5-hydroxy indol acetic acid and pediatric appendicitis score: A randomized control trial.

PURPOSE: Acute appendicitis in children represents a common problem. Diagnosis may be difficult due to lack of clinical data. Several scoring systems and laboratory investigations are used for diagnosis. This study aimed to build a model for diagnosis of acute appendicitis in children using urinary 5-hydroxyindoleacetic acid (5-HIAA) and pediatric appendicitis score. METHODS: This study was conducted on 191 children with suspicion of acute appendicitis. They were divided into two groups A and B. Children were evaluated in group A with pediatric appendicitis score, ultrasound, and CRP. In group B children were evaluated in the same manner of group A plus measuring of 5-HIAA. RESULTS: mean age was 13.3 ± 5.2 years. The mean duration of symptoms was 2.2 ± 1.4 days. The mean level of urinary 5-HIAA was 43.53 ± 24.05 in appendicitis patients in group B. In group A there were 65 cases who had appendectomy. Seventy-five children were operated in group B. Negative appendectomies were found in 13 and 7 cases in groups A and B respectively. Thirteen cases were readmitted in group A with diagnosis of acute appendicitis while seven cases were readmitted in group B. CONCLUSION: This combination of urinary 5-HIAA and pediatric appendicitis score builds a model for diagnosis of acute appendicitis in children. This model improves the accuracy of diagnosis of acute appendicitis, reduces both the incidence of negative appendectomies and the incidence of readmission or missed cases in children.

Analysis of Risk Factors of Pancreatic Injury during Elective Laparoscopic Splenectomy in Children.

INTRODUCTION: Laparoscopic splenectomy (LS) became the standard choice for splenectomy in children with benign hematological disease. There are few reports about pancreatic injury during LS. The purpose of this study is to spot on factors increasing the risk of pancreatic injury during LS in children. PATIENTS AND METHODS: A total of 140 children had LS for benign causes. Children were categorized into A and B groups. LigaSure™ was used to control pedicle in Group A, while endoscopic staplers were used in Group B. Preoperative levels of amylase, lipase, and lactate dehydrogenase (LDH) were obtained. The mean of pancreatic enzymes and LDH values was calculated on the 3 postoperative successive days. RESULTS: A total of 71 boys and 69 girls had LS. The mean splenic size was 13.50 cm in Group A and 12.51 cm in Group B. The mean operative time in Group A was 41.91 min and in Group B was 56.36 min. The mean level of amylase was 42.99 IU/ml in Group A and 75.70 IU/ml in Group B (P = 0.001). The mean level of lipase was 37 IU/ml in Group A and 76.66 IU/ml in Group B (P = 0.001). CONCLUSION: Pancreatic injury during LS is a rare complication usually presented on biochemical level. We believe that it is a hemostatic-dependent complication rather than splenic size or nature of disease.

Laparoscopic splenectomy in children with benign hematological diseases: Leaving nothing behind policy.

CONTEXT: Laparoscopic splenectomy (LS) is considered the standard approach for the treatment of children with nonmalignant hematological diseases due to the advances in the minimal invasive surgery over the conventional splenectomy (CS). Different techniques are involved in the operation to secure the hilum. AIM: The use of (Ligasure™) is a safe, effective, less time consuming and with less complications rate. MATERIALS AND METHODS: Sixty children (33 with thalassemia, 20 with immune thrombocytopenic purpura [ITP] and seven with spherocytosis) were operated during the period from June 2007 to December 2014. These children had undergone LS using (Ligasure™). Three ports were used in small-sized spleens while four ports were used in large spleens. RESULTS: There were 60 children (37 girls and 23 boys) with a mean age of 10.2 years had LS using Ligasure™ with mean operative time of 85 min for cases of ITP and 120 min for other cases. There was no mortality. Two cases were converted to CS. CONCLUSIONS: Use of Ligasure™ alone was safe, less time consuming with less complications rates.